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[To be'Returned to the, Circuit Clerk of the County in which the Death Occurs.]"
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Date of Death,........Y' 4 ' J
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Full Name^f Deceased, > ‘V
1871
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/Sex, ........................,i.:
^ ■	(/ () i () f1.	.J.L: *1...[.....	.	-J	...--—; 
5.	Age] (last birthday), .^.........	<%W *,	}
6.	Nativity,.,........../.2:Z.2r.i&.2:..	^
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7. Occupation,  ;  
8.	Disease, .............
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1 hereby
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r'eby certify that the abqy^is a true return of'’the death and other:
facts■ above recorded.
Dated	^	-
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f Attending Physician.
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Co unty of-...:.%L:di/j:l£j2Jux............
this......day of..cM£^m^87l...
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* State whiter White, Black, Mulatto,vfffifcah or other Races.	, ,	;*•
t Strike oulrthese words if the ^Return -bsjfeiade by some other person, and add other explanatory words.	"	]	)	'	!;•	•'	.	.••’■
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